Secrets of TEAM-CBT with Kids
Fabrice and David are pleased to chat with Dr. Taylor Chesney who is an expert in the treatment of children and teenagers with TEAM-CBT. Taylor was a member of Dr. Burns’ Tuesday group at Stanford and his Sunday hiking group for two years before returning to her home in New York in 2014. She opened the Feeling Good Institute NYC, where she and her colleagues offer individual and intensive treatment as well as training for mental health professionals (in person and online). Today she reveals the inside scoop on how to use TEAM-CBT with children and teenagers, and their parents.
Dr. Chesney begins by emphasizing that it is not hard to use TEAM-CBT with kids and teens, and that most of the tools work really well with only minor tweaking. For example, the Empathy tools (the Five Secrets of Effective Communication) work really well with kids and parents, and help you get buy-in so the kids and parents get excited about working together.
The Agenda Setting TEAM-CBT tools also need to be done with children as well as their parents.
Taylor credits Jacob Towery MD, one of her mentors in California, who taught her how to set up a four-session intake, so you get to connect with all family members before implementing any treatment techniques. She explains:
I’ll have two sessions with the child first, and one session with both parents together. This is really important to see how they’re experiencing parenting and how you can support them. The fourth session is the wrap-up session with the parents and the child together.
Empathy is vitally important from the very start. When I meet with the child or teen, it’s all about rapport building—their hobbies, friends, what they like, how they feel about their parents, what kinds of music they like, what apps and TV shows they like. This is their first time talking to you, and you have to get them to want to be with you. Building the relationship, the foundation, gives you so much leverage as you work with the child and the parents.
In the second part of the initial session with the child, we talk about symptoms, problems, and their take on it. Do they want help, or do the parents think they need help?
Fabrice: What if the child does not think they have a problem?
Taylor: I won’t work with a child unless they convince me they want help. I won’t take the parents’ money unless the child convinces me that they want help.
If they don’t want help, I tell the child I’ll work with their parents instead. However, I tell the child I’d prefer to work with them.
Fabrice: So, sometimes, the child cannot convince your that they want help.
I saw a child who got scared every night and wanted to sneak into the parents’ room to sleep. This was a problem for the parents, but the child didn’t want to change.
Some therapists might try to work with the child to persuade them to stay in bed, but if you do that, you’ll probably run into resistance. So, I said, “I get it. It’s not fun to sleep in your bed alone. You hear strange and frightening sounds so you naturally want to sleep in your parents’ room, where you feel safe. Still, your parents are saying, ‘this can’t go on.’ If you don’t want help, I’ll work with them, since they are asking for help.”
This got the kid wondering and he asked, “What would that look like if you worked with my parents instead of me?”
I said, “Every family is different, but if I work with you, you’d be in control, rather than your parents.” Then he decided, “I kind of think I want to work on it.”
It’s all the same techniques David has developed in TEAM-CBT—you just put the same concepts and techniques into the child’s language. You Sit with Open Hands, just like with adults. You don’t try to chase or sell the patient anything.
Taylor and Fabrice discuss the importance of motivation and avoiding battles you’re not going to win.
Fabrice asks for an example of how the treatment works, so Taylor continues:
There’s no one size that fits all. Every situation is so different. That’s why is so important to start with the relationship with the child.
A fun case is an 15 year old boy I saw. He was a stellar athlete and student, but was struggling with severe OCD and performance anxiety, including test anxiety. Several previous attempts at therapy had failed, including talk therapy and medications, but nothing had alleviated his severe anxiety and rituals.
I started with good empathy, using the Five Secrets to understand his hobbies, his friends. Then, instead of trying to “help” him, the way his parents and other therapists had been doing, I said something like this: “Your anxiety is part of your identity. It must be annoying to you for people to bug you to get over your anxiety.”
He got excited and seemed relieved, as if to say, “You’re not going to try to convince me to get over my anxiety?”
Everyone else was telling him he shouldn’t be so anxious, so he got to thinking, as we all do, that his anxiety was somehow “bad.” In contrast, we looked at all the great things his anxiety showed about him, and how he cared about his performance, and all the things he had to do each day. How he wants to be successful, and wants to get positive feedback from his teachers and make his parents proud of him.
In other words, we came up with lots of GOOD reasons to hold on to his anxiety. This is exactly how we’d deal with Outcome Resistance in an adult.
The floodgates opened up, and he listed all the many really good reasons to continue to be anxious. He said it was the best session ever, and no one else had ever agreed with him about all the good reasons to be anxious.
Then we talked about the Magic Dial—was there some area where a lower level of anxiety would be enough? He decided to work on test anxiety first, because he froze up on exams. He said he didn’t need that much anxiety!
We also talked about what he’d have to do to overcome his anxiety that he might not want to do. In TEAM-CBT lingo, this is called dealing with Process Resistance. There were lots of things. First, he’d have to risk it and be willing to accept the possibility of getting lower grades and being okay with the outcome of the exam, and he’s also have to use the Daily Mood Log every day to record his negative thoughts and challenge them.
Fabrice: You talked about his willingness to get lower grades. Is that a way of dealing with his Outcome Resistance?
I thought of it more as him facing his fears—exposure, in other words. He thought he had to do a certain ritual before each exam and rehearse his answers repeatedly on the exam in order to get a really high grade. If he agrees to give up those rituals, he’ll be facing his fears.
Teenagers can use the same Daily Mood Log that David has developed for adults. He was thinking:
- I shouldn’t worry.
- I should get 100 every time.
- No one else worries.
- Everyone will think I’m stupid if I don’t get a really high grade.
- Then no one will like me.
- Everyone is smarter than me.
Fabrice asked about the Emotions Table on the Daily Mood Log, so Taylor spoke about psycho-education about emotions, and the importance of asking them to circle their negative feelings on the Daily Mood Log. This gives them a better understanding of their emotions, and gives them a vocabulary to talk about how they’re feeling.
Taylor also explains about how to put the Cognitive Distortions in child-friendly language. Instead of All-or-Nothing Thinking you can talk about “all good” or “all bad.” She also makes it a game and asks kids to learn about one distortion each week. Like, making the child a Should Detective for a week, looking for Should Statements in themselves and others. They have fun with this.
Fabrice asked what happened to the anxious teenager once the Empathy and Agenda Setting had been completed.
She described a variety of TEAM-CBT methods that were useful to this boy, starting with the Survey Technique—ask your friends if it is true that no one else worries, or if they’d think less of him or not want to be his friend if he didn’t get a good grade on a test. Taylor also used Self-Disclosure, encouraging him to share his insecurities instead of hiding them.
Taylor said the Double Standard Technique also helped him a great deal, along with the Externalization of Voices, the Feared Fantasy, Acceptance Paradox, and more, so he could practice talking back to his negative thoughts. Taylor explained how to make the role-playing more fun with kids, introducing an element of play.
Fabrice: How do kids take to the Acceptance Paradox? How do they switch their thinking?
They spend so much of their life thinking their anxiety is bad, but in Agenda Setting they see there are really good parts of the anxiety, so they stop resisting and see they no longer have to fight the anxiety. One of his thoughts was, “I shouldn’t feel anxious on exams, I shouldn’t feel this way,” but those Should Statements simply feed his anxiety and make it worse. The Acceptance Paradox moved in the opposite direction, so he could say, “my anxiety is okay.”
He responded well and is no longer my patient. It’s sad to lose patients who recover fairly quickly, but it’s also great to witness the change and get feedback on how well they are doing later on.
Another thing we also did was Exposure, asking him to bring in a test and then we induced anxiety in the office.
In the initial treatment, we only focused on his test anxiety, because that was his agenda. But he came back a year later asking for help on other issues, which also went really well.
Fabrice: It sounds like the initial therapy was a trust builder, giving him what he wanted, and no more. You walked the walk with him and put him in control.
Taylor: Yes. You also have to build a good relationship with the parents, so they trust you and your therapeutic strategy as well. They were on board and let him work with me in this manner.
If you would like to contact Dr.Taylor Chesney with a question, or for treatment or training in TEAM-CBT, you can call her at 516-551-8063, email her by clicking here or visit her website. To register for her next online training group, click here.
If you have specific questions about the treatment of children or adolescents, make sure you contact her, as we may be able to set up a second podcast with Taylor!
Coming Up Soon–
Step by Step Training for Therapists
by David Burns, MD and Jill Levitt, PhD
Learn how to reduce patient resistance and boost motivation to change. Master skills that will enhance communication skills and increase intimacy with loved ones. This workshop is highly interactive with many case examples and opportunities for practice using role plays.
Join us for a day of fun and inspiring learning on site in Palo Alto OR online from anywhere in the world by this dynamic teaching duo!
Sunday October 28th, 2018 (9am-4pm PST) 6 CE*s. $135
To register, go to Feeling Good Institute
* * *
Rapid Recovery from Trauma
a two-day workshop
by David D. Burns, MD
October 4-5, 2018–Woodland Hills, CA
November 1-2, 2018–Pasadena, CA
The November workshop includes Live Streaming
if you cannot attend in person)
For further information, go to http://www.IAHB.org
or call 1-800-258-8411